Neuro Emergencies Flashcards
- Consciousness has 2 main components what are they?
2. Describe how they are different in Delirium and Dementia?
- Arousal and Cognition.
- Delirium: alteration of both arousal and cognition. Dementia: alteration in cognition, not arousal
- Arousal is controlled by the what?
2. Cognition is controlled by ?
- ascending reticular activating system (ARAS) in the brainstem.
- cerebral cortex.
AMS - PE
3
- ABCs; Vital signs
- Bedside glucose
- Look quickly for immediate life threats
AMS PE
Look quickly for immediate life threats, such as:
5
- Hypoglycemia
- Hypotension/ Hypertension
- Hypoxia
- Abnormal respirations
- Hypo/ Hyperthermia
AMS PE Head to toe exam 1. Head? 5 2. Neck? 1 3. CV? 3 4. Pulm? 1 5. Abd? 2 6. Skin? 4
- Head –
- trauma;
- Pupil size, symmetry, and reactivity.
- Pinpoint pupils: OD vs pontine hemorrhage;
- Blown pupil: uncal herniation;
- Fundi: papilledema - Neck – stiffness?
- CV –
- dysrhythmia (atrial fib),
- murmurs (endocarditis),
- rubs (pericarditis) - Pulm-
- symmetry of sounds, rate, wheezes - Abd –
- masses?
- Organomegaly? (alcoholic liver, splenic sequestration in sicklers) - Skin –
- color,
- turgor (dehydration);
- rashes (petechiae, purura: TTP vs meningococcemia?);
- Infection (cellulitis, fasciitis)
AMS – DDx: AEIOU TIPS
A – Alcohol E – Epilepsy; Electrolytes; Encephalopathy (HTN, Hepatic) I – Insulin (hyper and hypo); Intuss (peds) O – Overdose; Opiates U – Uremia T – Trauma; Temperature (Hyper and hypo) I – Infection; Intracerebral hemorrhage P – Psych; Poison S - Shock
When would you intubate?
GCS less than 8
Are they brain dead/herniating?
PE?
6
- DTR
- Cranial nerves best they can
- responsive to pain
- suction and see if they have a cough or gag reflex
- dolls eye test- stays in line is bad
- anyone with a blown pupil is uncle herniation until proven otherwise
Status Epilepticus
1. Considered how long without return to preconvulsive neurologic baseline?
- Traditionally considered to be convulsions > ______, however do not halt treatment!
- 5 minutes or more of convulsions or 2 or more convulsions in a 5 min interval
- 30 min
Status Epilepticus
Etiologies
6
- Vascular: stroke, SAH, hypoxic encephalopathy
- Toxic: drugs, alcohol withdrawal, medications (Isoniazid, TCA’s, chemo agents), AED non-compliance
- Metabolic: Hyper/hypo-natremia, hypoglycemia, hypocalcemia, liver/renal failure
- Infectious: meningioencephalitis, brain abscess
- Trauma
- Neoplastic
Initial Assessment/Treatment of status epilepticus
3
1, ABC’s – O2, airway, BP
Monitor for hypotension
2. Labs:
3. Dx hypoglycemia as cause
Initial Assessment/Treatment of status epilepticus
5
- CBC,
- BMP,
- Ca,
- Mg,
- AED levels
How would you treat status epilepticus if hypoglycemia was the cause? 2
- D50W amp and Thiamine 100 mg IV
- Needs to have thiamine given before dextrose as 20-40% of seizure pts are alcoholics
Treatment for status epilepticus:
- Initially? 2
- Then? 2
- Refractory? 4
- Benzodiazepines are first line
Ativan 4mg IV or Valium 5mg IV - Second line
-Fosphenytoin load 20 mg/kg (up to 150 mg/min)
-Valproic acid load 40 mg/kg, 2nd dose of 20 mg/kg - Refractory status
- Phenobarb 20 mg/kg,
- Pentobarb,
- Versed gtt,
- Propofol, etc.)
Post-ictal State
- What do we have to differentiate this from?
- What does the post ictal state consist of? 4
- tx?
- Work up?
- Differentiate post-ictal state and syncope of another cause
- Post-ictal state
- Usually sleepy and may be confused
- During the possible prior seizure the pt has usually been incontinent
- Tongue bitten - Supportive care
- Work up why seizure occurred
Acute Ischemic Stroke
- Caused by? Results in?
- Within seconds to minutes of loss of perfusion, an ischemic cascade occurs resulting what?
- Goal of tx?
- Caused by the sudden loss of blood circulation to an area of the brain resulting in ischemia and corresponding loss of neurologic function
- a central area of irreversible infarction surrounded by an area of potentially reversible ischemic penumbra
- Goal of treatment is to preserve ischemic penumbra
Acute Ischemic Stroke
Hx questions?
4
- Time last known well
- tPA contraindications?
- History of diabetes? Seizures?
- Detailed description of symptoms
Acute Ischemic Stroke
Detailed description of symptoms such as
1. What would indicate ICH? 3
- What about a vertebral or carotid dissection? 2
- Onset with HA,
- seizure,
- syncope .. Possible ICH..
- Neck pain,
- history of neck trauma ..
Possible vertebral or carotid dissection
PE for acute ischemic stroke?
7
- Level of consciousness
- Eye exam
- CN exam
- Motor exam
- Sensory exam
- Reflexes
- Cerebellar exam
Work up: Acute ischemic stroke:
- Labs? 6
- Imaging?
- Labs:
- POCT BG,
- CBC,
- CMP,
- PT/INR,
- cardiac enzymes,
- EKG - Imaging:
- Emergent non-contrast head CT